Ulnar osteotomy is the only required procedure for chronic monteggia fracture in children.

Objective: To determine containment of radial head after ulnar osteotomy in chronic Monteggia fractures. Study Design: Retrospective study. Setting: Children Hospital and The Institute of Child Health, Lahore. Period: 2019 to January 2020. Material & Methods: Ten patients presented in outdoor patient department with a diagnosis of chronic Monteggia fracture. Four patients were labelled as missed Monteggia fractures, four with late presented Monteggia fractures and two with inadequately treated Monteggia fractures. Bado and Letts classifications were applied for patients. Mean age was 6 years and 8 months and ranged from 4 to 10 years. Mean time interval between injury and admission was 6.1 months. Open reduction of radial head and ulnar osteotomy was done through Boyed approach. Transcapitellar wire was inserted temporarily and then removed so it is not required permanently. The ulnar osteotomy was angulated opposite to the direction of radial head dislocation and fixed with plate and screws. Results: 10 patients were included in this study. The age range was between 4 and 10 years. The study period was six months and follow up was one year. Mean ulnar angulation at osteotomy site was 21.3° (16-25°). Mean ulnar lengthening at osteotomy site was 0.85 cm (0.5-1.8 cm).Improvement in flexion-extension was 20.3%, pronation was 5.1% and supination was 13.7%. Complications included were nounion in 1 case and cubitus valgus in 1 case. Conclusion: Containment of radial head is obtained by open reduction of radial head and with ulnar osteotomy in chronic Monteggia fractures. Annular ligament reconstruction and transcapitellar wire insertion are not required if proper angulation and fixation of ulnar osteotomy is performed. No age limit for this procedure but surgery should be performed before radial head deformation.

A novel technique of annular ligament reconstruction using extensor carpi radialis longus tendon fascia: a report of 3 cases

<p class="abstract">Annular ligament is an important stabiliser of radial head. In cases of chronic radial head dislocation, annular ligament reconstruction is warranted to maintain radial head reduction to improve elbow function. We have reported here a novel technique using the fascia overlying extensor carpi radialis longus tendon for annular ligament reconstruction. We reported an average flexion of 130º and full supination in all 3 cases. 2 patients achieved mid pronation and 1 achieved full pronation; comparable with other described techniques. Our novel technique through a single incision has excellent functional outcomes. Additionally, it is simple, cost effective, requires no hardware.</p>

Treatment of missed Monteggia fracture with intact annular ligament after an interval of 9 years: a case report and literature review

Objective Missed Monteggia fractures are commonly observed among children. Both the interval from the injury to surgery and the patient’s age at operation are thought to be correlated directly with the success of the surgery and prognosis. The aim of the present work was to report one interesting adult case of a missed Monteggia fracture with an intact annular ligament 9 years after injury and the outcomes at a 7-year follow-up. Case description One missed lesion with a 9-year delay for surgery occurred in a skeletally mature individual, and it was treated by open reduction and ulnar angulation and elongation osteotomy. The annular ligament was interpositioned intact in the radiocapitellar joint, and therefore, instead of the annular ligament reconstruction (ALR), relocation was performed. Results After one revision surgery for the complication of nonunion, good radiographic and functional outcomes were eventually sustained at the 7-year follow up. Conclusion Good radiographic and functional outcomes can be expected in adult patients in whom the annular ligament is intact and interpositioned, and this was treated by open reduction and ulnar osteotomy 9 years after the initial injury in our patient.

Step-cut osteotomy in neglected Monteggia fracture dislocation in pediatric and adolescent patients: A retrospective study

Introduction: Neglected Monteggia fracture dislocation in children leads to significant restriction of daily activities by causing decreased range of motion at elbow, stiffness, deformity, and neurological compromise. Various treatment strategies have been described in the literature and one of them is ulnar osteotomy combined with reduction of radial head and annular ligament reconstruction. Aim: The aim of this study was to evaluate the results of step-cut osteotomy without the use of bone grafting with reconstruction of annular ligament in the management of neglected Monteggia fracture dislocation in children. Materials and Methods: A retrospective study was conducted in six patients with neglected Monteggia fracture dislocation with a mean age of 8.83 years. The median interval between the original injury and the corrective surgery for 6 patients was 4.4 months (range 1–12 months). All children underwent step-cut osteotomy of ulna, open reduction of radial head, and annular ligament reconstruction. Mayo Elbow Performance Index (MEPI) score was used for evaluation. Results: The ulnar osteotomies healed uneventfully without the need for a bone graft. Elbow range of motion improved post-op along with improved elbow functioning as indicated by raised MEPI score. The MEPI score was excellent in 5 cases and fair in 1 case. Conclusion: Step-cut osteotomy alone without the use of bone grafting and reinforcement with annular ligament repair is a simple yet effective technique for treating neglected Monteggia fracture dislocation.

A prospective study on surgical management of neglected Montaggia fracture in children without annular ligament repair

<p class="abstract"><strong>Background:</strong> Monteggia fracture presenting after 4 weeks of injury termed as neglected monteggia fracture.There are many options for management of this fracture. The present study was planned with objective to assess clinical outcome of patients who were treated with a specific technique of ulnar osteotomy without annular ligament repair.</p><p class="abstract"><strong>Methods:</strong> This prospective study was conducted in Department of Orthopaedics MKCG Medical College and Hospital, Berhampur from July 2015 to April 2018 where 15 patients of neglected monteggia fracture were operated with specific technique of ulnar osteotomy without annular ligament repair. Participants were followed up and at end point they were evaluated for pain, stability, and disturbance of daily and sporting activities. Function was assessed using elbow performance score. Data collected were analyzed in SPSS (version 16.0).<strong></strong></p><p class="abstract"><strong>Results:</strong> Mean age of study participants was 7.3 year and male constituted majority (60%). There were 11 children with Bado type I, 3 with type II and one with type III injury. The mean time from initial injury was 8.8 months. All had limited range of movements of forearm and elbow. All patients had regular follow up for 9 months to 24. In 53.3% flexion arc was improved. The mean flexion arc was increased by 20 degree and pronation-supination arc was reduced by 20 degree.</p><p><strong>Conclusions:</strong> The present study revealed that osteotomy in neglected monteggia fracture brings stability of elbow joint and this surgical management of neglected monteggia fracture without annular ligament reconstruction had good outcome. Annular ligament reconstruction is not always necessary.</p>

Surgical treatment of chronic anterior radial head dislocations in missed Monteggia lesions in children: A rationale for treatment and pearls and pitfalls of surgery

Introduction The treatment of chronic radial head dislocations after Monteggia lesions in children can be challenging. This article provides a detailed description of the most frequently performed surgical technique: an ulna osteotomy followed by annular ligament reconstruction. Accordingly, we present the clinical and radiological results of 10 paediatric cases. Material and methods All paediatric patients that had a corrective osteotomy of the ulna for a missed Monteggia lesion between 2008 and 2014 were evaluated with standard radiographs and clinical examination. A literature search was performed to identify the relevant pearls and pitfalls of surgery. Primary outcome was range of motion. Results We included 10 patients, with a mean follow-up of 2.5 years. Postoperative range of motion generally improved 30.7°. Even in a patient with obvious deformity of the radial head, range of motion improved after surgery, without residual dislocation of the radial head. Conclusion Corrective proximal ulna osteotomy with rigid plate fixation and annular ligament reconstruction yields good results in patients with chronic radial head dislocation following a Monteggia lesion. Surgery should be considered regardless of patient age or time since trauma. Given substantial arguments in literature, we discourage surgery if a CT scan shows dome-shaped radial head dysmorphic features in work-up to surgery.

Angulating-Distraction Ulnar Osteotomy and Interpositional Phosphocalcic Ceramic Wedge Graft for a Chronic Monteggia Lesion

Background: Various types of osteotomies have been used to facilitate reduction of the radial head and to prevent recurrent subluxation. The Bouyala technique – open reduction of radial head associated with open wedge ulnar osteotomy with or without annular ligament reconstruction, is presently the most widely used treatment for long- standing traumatic dislocation of the radial head, independently of age, in the absence of osteoarthritis remodeling, and should preferably be performed within 1 year of trauma. Method: In this article, we present a similar case operated by same technique, but we used synthetic phosphocalcic ceramic wedge graft instead of auto bone graft as described in many other studies. We believe that, this will limit the donor site morbidity and also aid in achieving better stability at osteotomy site, which in turn help in proceeding with early active mobilization protocol. Result: We achieved union of the osteotomy by three months. Clinically, there was no deformity and she achieved full pain-free range of motion of elbow joint. Conclusion: We believe that, use of synthetic phosphocalcic ceramic wedge graft allow rigid fixation of osteotomy, provides additional stability, decrease the risk of secondary displacement and allow early mobilization, which may minimize contracture and we could achieve fairly good clinical outcome.